- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,187.76 / $5,888.44
| Professional | | $2,089.30 | $2,187.76 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $7,943.28 / $9,549.93
| Professional | | $4,897.79 | $7,943.28 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,981.07 / $5,495.41
| Professional | | $3,090.30 | $3,981.07 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,090.30
| Facility | | $1,288.25 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,786.30 / $8,128.31
| Professional | | $2,691.53 | $4,786.30 | $8,128.31 |